Pain Neuroscience Education: Dead or Alive?

Twitter was buzzing a few days ago with the posting of a new paper that came out on November 5th in JAMA Neurology. Adrian Traeger and his fellow collaborators published an excellent study looking into the effects of pain education for patients with acute low back pain. It was interesting to read the replies and repost of the article on Twitter with comments such as: “game changer”, “challenging my biases”, “Explain Pain hits a snag”, “education not helpful”, and others.

I thought I would offer a few thoughts on what I took home from the study but could not do it in 280 characters, so here it is in blog format.

One thing I think we all need to keep in mind is that pain is multidimensional and thus leads to being very heterogeneous. The idiom, “If you have seen one, you have seen them all” does not work for a person in pain. When you have seen one person in pain, you have seen one person in pain. We need to move past the thinking that any ONE intervention (pain science education included) is going to be the panacea for all pain related problems. Pain is too complex and multidimensional for that ever to work.

Can ONE intervention be the ONE thing, ONE patient needs, sure. However, ONE intervention cannot be the ONE thing, ALL patients need.

First, the authors should be commended on such an excellent well-controlled research study. There was a significant amount of effort put into controlling the two different interventions. I encourage everyone to not only download the study but also get the comprehensive Supplementary Online Content provided. They detailed out all of their education that was provided. My only caution would be that this study was done in Sydney, Australia and I think we need to be careful and realize that education should be delivered in culturally competent manner and individualized to the person in front of us because of the multidimensionality of pain. Therefore, education in one region of the world may not sound the same in another. It may actually sound different to two different people in the same part of the world.

So what did the study find? My interpretation was that two one-hour sessions of intensive pain education alone was not superior or inferior to the outcomes of just providing listening, showing interest, and attention of the clinician for those with acute low back that were at risk for chronic pain. Both groups showed some good improvements in pain and function within a few weeks and long term over one year.

Here are my biases that were confirmed with the study results:

Most acute problems get better through natural progression. Make sure we are providing some reassurance to our patients about this very important fact and do not over treat them.

Therapist-patient interaction of listening, showing interest, and attention (aka. Therapeutic alliance) maybe plays an important role in outcomes. Both groups got better with listening, showing interest and providing attention. We cannot fully deduce this from this study if that is the case, as it was not designed for that question. We do have other studies that do back up the importance of the therapeutic alliance. What this study did show that by providing pain science education you are able to maybe develop some of the elements of therapeutic alliance to help with outcomes. More research would be needed, but this study leads to some evidence that providing pain science education maybe one method that can develop therapeutic alliance and produce just as a good of result as the “placebo patient education” method. (We can argue if it should be called placebo education, but I won’t go there at this time)

Our systematic review back in 2016 we found that education alone (which from my understanding of the methods of this study is what they provided) does not seem like the best approach. If anything education needs to be paired with active treatment and other helpful interventions, something we have referred to as PNE+.

Potentially too much education (intensive 2 hours) may not be needed. In my case report published back in 2013, I provided 20 minutes of pain education to a similar type of patient that might have been in this study. The “fire hydrant approach” of giving intensive education might be better switched to a lighter version of sprinkling in some shorter less intense pain education with PNE+ interventions. Others might argue that we need more than 2 hours to make the changes that are needed through pain education. Only more research can answer that question.

Areas of interest and future study as we continue to unpack pain education’s role in the care for people in pain.

My first area of interest is to see the other secondary measures (eMethods 5) the authors collected and looks like will be publishing separately in a planned mediation analysis.

Another is perhaps the idea that pain neuroscience education might be a way of developing a therapeutic alliance? Something that we are currently in the works of investigating.

The last would be the idea about dosing of pain neuroscience education. How much pain neuroscience education is needed and how much pain knowledge does the patient really need? Do we need 2 hours, maybe only 20 minutes, maybe 2 minutes, maybe none?

For me this was a great study that continues to add to the understanding of how to best utilize pain science education and creates many more avenues for study as we work to understand things further. For me no one study is ever a “game changer”, hopefully I’m always challenging my biases, I don’t think this study shows all education is not helpful, and every study should put a snag into things by creating more questions to explore.

Curious to hear what others are thinking and how their views have been changed or confirmed based on this study. In addition, if you have interest in future study of how to best use pain neuroscience please contact us at ISPI and our Pain Neuroscience Research Group, we are always looking for research and clinic collaborators.

14 responses to “Pain Neuroscience Education: Dead or Alive?”

After reviewing the supplementary material, I have a couple of thoughts. First, the method of education used is more than I would do at one time and more information than I would give. It seems like information overload; too much to take in and adequately process. Second, I try to stay away from the word “brain” as long as possible. As soon as you say brain, it becomes “all in my head”. I begin by talking about the sensitive nervous system/alarm system, then move onto nerve sensors/ion channels, possibly next to the role of stress via the sympathetic nervous system. This is done in small 10-20 minute chunks, while I am reassuring the patient that what they are experiencing is normal and will get better with some time and tender-loving-care. If it seems important, I might eventually talk about the brain as the big boss or how the brain is like a parent, always looking out for its child and weighing threat vs. safety.
I do agree with Kory that this looks like a well done study and a necessary study, but it is not a “game changer”.

Kory…
Sure appreciate your perspective here and agree with your summation of the research. I have a few thoughts…

1. Truth should always be shared in grace. We know the truth about pain…that it is output, not input…that the nervous system can physically and neurologically change in response to it…that it is incredibly comples, personal, emotional, multifactorial. Sharing this is imperative and right. No matter the outcome. How we share it and how it is received are immeasurable variables however. This goes to the art of treating the person as an individual.

2. It is not “either/or” rather “both/and”. Often research, (or even our method of treatment) becomes an “either/or” proposition. We make choices based on biases, strengths/weaknesses, preferences, known truth. The variation here is impossible to measure. Research, by nature, offers an “either this or that” proposal. In incredibly simplifies a known incredibly complicated and intricate issue. It sheds a pinpoint of light on the table of truth for us to extrapolate the remainder of truth from a small amount of fact.
3. Facts don’t always lead to Truth. We know this simply from pain science. For hundreds (or perhaps thousands) of years, we were convinced as to how pain worked and formed trillion dollar industries, adervtisement campaigns, training, research around a belief of perceived truth based on facts we observed…only to find those beliefs were based on false assumptions from the facts. We should all be careful about forming hard criteria about how to best treat the individual while simultaneously striving to make those individualized treatments better and more effective on an ever increasing measure.
4. No one has the corner on Truth. Not one person or entity has concluded the whole Truth on any one matter. This is why Truth seems to change. In fact (um, Truth), it does not change…only our discovery of it changes. As we find out more Truth, our extrapolation of the whole Truth changes to become more and more and more like the actual Truth. Sort of like trying to describe a football stadium in the dark while holding a candle. The Truth is that the stadium exists. The facts of our observations are known. However, to accurately describe the stadium would be impossibly. We need more light to do this.

This is particularly why evidence based treatment is not the end of it all…because we never have all of the Truth. And, it, by it’s nature, is self limiting and creates inherent biases. Take it for what it is. Come back to principles that don’t change even despite the new discovery of facts. We will find that those that things which remain unchanged despite new facts are the things we should be tightly hanging on to.

Kory…
Sure appreciate your perspective here and agree with your summation of the research. I have a few thoughts…

1. Truth should always be shared in grace. We know the truth about pain…that it is output, not input…that the nervous system can physically and neurologically change in response to it…that it is incredibly complex, personal, emotional, multi-factorial. Sharing this is imperative and right. No matter the outcome. HOW we share it and HOW it is received are immeasurable variables however. This goes to the art of treating the person as an individual.

2. It is not “either/or” rather “both/and”. Often research, (or even our method of treatment) becomes an “either/or” proposition. We make choices based on biases, strengths/weaknesses, preferences, known truth. The variation here is impossible to measure. Research – by nature – offers an “either this or that” proposal. It incredibly simplifies a known, incredibly complicated, and intricate issue. It sheds a pinpoint of light on the table of Truth for us to extrapolate the remainder of truth from a small amount of fact.
3. Facts don’t always lead to Truth. We know this simply from pain science. For hundreds (or perhaps thousands) of years, we were convinced as to how pain worked and formed trillion dollar industries, advertisement campaigns, training, research, etc. around a belief of perceived truth based on facts we observed…only to find those beliefs were based on false assumptions from the facts. We should all be careful about forming hard criteria about how to best treat the individual while – simultaneously striving to make those individualized treatments better and more effective on an ever increasing measure.
4. No one has the corner on Truth. It is wise to realize that myself or any other person or entity has concluded the whole Truth on any one matter. This is why Truth seems to change. In fact (um, Truth), it does not change…only our discovery of it changes. As we find out more Truth, our extrapolation of the whole Truth changes to become more and more and more like the actual Truth. Sort of like trying to describe a football stadium in the dark while holding a candle. The Truth is that the stadium exists. The facts of our observations are known. However, to accurately describe the stadium would be impossible. We need more light to do this.

This is particularly why evidence based treatment is not the end of it all…because we never have all of the Truth. And, it, by it’s nature, is self limiting and creates inherent biases. Take it for what it is. it is important…but not everything. Come back to principles that don’t change even despite the new discovery of facts. We will find that those that things which remain unchanged despite new facts are the things we should be tightly hanging on to.

I appreciate your insights here. As always, you have great perspective. This is why evidence-based-practice is not merely following the research… if it was, we’d be blown about in the wind more often than not! Rather, it’s that sweet spot where what we “know” about Truth from the literature meets what we know of Truth from our experience and what the patient brings to the table in terms of their values and knowledge. Thanks for such a thoughtful discussion.

Great discussion! Maybe the best blog/posts Seen in a long time. One huge takeaway is that we should spend at least as much time educating as we spend in providing passive interventions. In fact, until we are actually reimbursed fairly for educating, maybe an optimal time to educate is actually during those passive components of care. Keep this discussion going please!

Thank you for such an articulate and well-thought-our post. I love the notion that providing PNE might be considered a way to build TA. Making the unknowns known, which is the hallmark of PNE, certainly can calm fears, and I for one tend to feel more connection and trust with those who have taken the time to calm legitimate fears that I have. On the flip side, those who I trust and feel connected to are more likely to be able to calm the fears I have. So, I think the two (TA and PNE) definitely go hand in hand, mutually reinforcing each other, and both bringing benefit to the patient.

The other point you made that made me want to shout “Amen!” is the idea of dosing PNE. Delivering PNE is soooo individual. What story works for one person may fall on deaf ears for another. One person may need just a simple 10-15 min session of PNE to have that “ah-ha” moment, whereas others may need to hear the same message delivered 5 different ways before it sinks in.

I’m sure there are several factors which determine what doseage of education is appropriate for an individual, such as level of fear, firmness of entrenched biomedical/ biomechancical beliefs, and self-efficacy. However, there are so many confounding variables, due to everyone’s unique “fingerprint of pain,” that research may struggle to show hard and fast patterns, as Paul mentioned in his response. In general, I have found individualized, PACED PNE, in combination with many of the great treatment techniques we have at our fingertips (i.e. exercise, movement therapies, sleep hygiene), etc., truly changes the lives of many of our patients.

Thank you for getting this conversation started and kudos to all who have chimed in!

Thanks for your insights, Kory…..
I agree that it was a good study and that sometimes this kind of results are needed to differentiate our thoughts on PNE. But on the other hand one is left with feelings like:
I do not think a 90 min PNE session with an acute LBP patient is advised, I would rather have listened for distress [anxiety/fear] and tried to calm the brain down while examining and treating the patient with explanation of the acute pain and the feelings going with it…….
We will have to understand [assess] when extended PNE is really necessary?

Good point. Most of the people I see have chronic pain so time spent on PNE makes more sense. When I do have a person with acute LBP/neck pain/knee pain/etc., I spend more time normalizing symptoms and setting positive expectations for improvement – “While what you are experiencing is definitely unpleasant, it is quite normal. This sort of thing happens to a lot of people. Based on what we found today, this is very likely to get better. You should be back to your normal self in fairly short order!”

Good stuff. We certainly need guidance on dosages and frequency of PNE. Additionally, since patients are highly individualistic, can we somehow classify patient subsets, and doesn’t every patient with chronic conditions need at least some PNE? Finally, can telehealth play a role in reaching out to augment in clinic intervention?

One could argue that all patients need PNE. But realize that for a patient with acute pain PNE may be as simple as: “Looks like you irritated some structures in your back and you will bit a bit sensitive for awhile as the tissues heal, but there is nothing sinister going on to stop us from starting your rehab.” – it certainly would not need an hour or so of education to provide that message.

Obviously the more complex the pain experience with more multidimensional layers and the longer it persists will take a bit more PNE time.

We do think that telehealth and use of VR is definitely something to augment in the clinic and we are working on it. :)